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Metastatic renal cell carcinoma

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					                                                                                                         Thorax 1987;42:901-902



Metastatic renal cell carcinoma mimicking pleural mesothelioma
D R TAYLOR, W PAGE, D HUGHES, G VARGHESE
From the Departments of Medicine and Pathology, The Queen's University ofBelfast

Renal cell carcinoma is renowned for its propensity to meta-           lesion was found in the lungs or at the hila. Histological
stasise in unusual ways. While the thorax is the most fre-             examination showed vacuolated polygonal cells diagnostic
quently affected site, pleural lesions are uncommon, and me-           of renal cell carcinoma. Immunocytochemical studies
tastasis is usually associated with parenchymal lung lesions. I        confirmed the tumour to be renal in origin and excluded the
We report a case in which pleural metastatic disease was the           possibility of mesothelioma. Positive results on testing with
sole intrathoracic abnormality and the clinical, radiological,         epithelial membrane antigen, low weight cytokeratin (kidney
and pathological features were identical to those of pleural           associated epithelia), vimentin, and periodic acid-Schiffindi-
mesothelioma.
Case report
A 67 year old man presented with a six week history of dry
cough, increasing dyspnoea and left sided pleuritic chest
pain. He had been a lifelong smoker (40 pack years) and had
been exposed to asbestos 25 years earlier while working as a
boiler engineer. At the age of 56 years a right sided renal cyst
had been drained surgically. He denied any urinary symp-
toms.
   Physical examination showed an obese (85 kg), afebrile
man with signs of a left sided pleural effusion. A firm, non-
tender mass measuring 6cm in diameter was felt in the left
hypochondrium. Examination of the urine showed numer-
ous pus cells but no red cells.
   The effusion was aspirated and pleural biopsy specimens
were obtained, but cytological examination of the fluid
failed to reveal malignant cells. The chest radiograph, taken
after aspiration (fig 1), showed a lobulated pleural opacity
extending into the paratracheal area and the presence of               Fig 1 Chest radiograph taken after aspiration of the left
residual fluid. Computed tomography of the thorax (fig 2)              sided pleural effusion, showing the lobulated pleural opacity
and abdomen showed appearances suggesting a diagnosis of               extending into the paratracheal area.
mesothelioma or metastatic disease; no pleural plaques were
identified. Abdominal scans indicated a solid rather than
cystic mass arising from the parenchyma of the left kidney.
The appearances were typical of a renal cell carcinoma.
   Reaccumulation of pleural fluid was managed by tempo-
rary insertion of an intercostal drain and tetracycline pleu-
rodesis. The patient remained symptomatically stable for
four months, but then deteriorated and died in respiratory
failure.
   At necropsy the left pleural space was completely oblit-
erated by white fleshy tumour, encasing the lung and pene-
trating the pericardium and diaphragm. The macroscopic
appearances were indistinguisable from those of pleural
mesothelioma. In addition, the tumour had extended along
the track of previous intercostal drainage, ending in a 4 cm
lobulated subcutaneous mass. No other discreet metastatic

Address for reprint requests: Dr G Varghese, Level 8, Belfast City
                                                                                 Rommommones-
                                                                                                             n          M..   All-
Hospital, Belfast BT9 7AB.
                                                                       Fig 2 Computed tomography scan of the thorax, suggesting
Accepted 23 January 1987                                               a diagnosis of mesothelioma or metastatic disease.
                                                                 901
902                                                                                       Taylor, Page, Hughes, Varghese
cated a renal origin. Negative results with 52 kD cytokeratin     be bilateral in their distribution, might have had an im-
and MHFG2 excluded a primary mesothelioma.2                       portant effect on tumour behaviour after the establishment
   In the right lung the pleura was grossly thickened,            of a single pleural metastasis.
although no plaques were seen. Asbestos fibres, mild                One other feature makes this case unusual. The spread of
fibrosis, and alveolar wall thickening, diagnostic of early as-   tumour along the track of a previous intercostal drain in-
bestosis, were widely distributed subpleurally. In the abdo-      sertion is characteristic of mesothelioma and has been ob-
men the presence of a large renal cell carcinoma arising from     served after diagnostic thoracotomy,6 but has only rarely
the left kidney was confirmed, and in the right kidney a          been reported in cases of renal cell carcinoma after needle
single 0 5 cm metastatic deposit was found.                       biopsy.7
                                                                     Finally, renal cancer has been found to occur at twice the
Discussion                                                        anticipated rate in a large series of asbestos exposed
                                                                  workers.8 Whether in our case asbestos exposure was of
The thorax is the most common site for metastasis from a          aetiological significance cannot be established. The case is a
renal cell carcinoma, being affected in up to 55% of cases at     reminder, however, that asbestos is a possible cause of some
necropsy. Multiple pulmonary nodules are most frequently          non-respiratory tract tumours.
found, but single nodules, lymphangitis carcinomatosa, hilar
and mediastinal adenopathy, endobronchial obstruction, References
and thoracic wall lesions also occur. 1 3 4
   Although uncommon, pleural lesions with or without I Bennington JL, Kradjian RM. Distribution of metastases from
effusions are by no means rare, occurring in about 4% of          renal cell carcinoma. In: Bennington JL, Kradjian RM, eds.
cases. What is unusual about the present case is that the         Renal carcinoma. Philadelphia: WB Saunders, 1967:156-7.
clinical behaviour and pathological features of the pleural 2 Bolen JW, Hammer SP, McNutt C. Reactive and neoplastic sero-
metastasis so strikingly resembled that of a primary meso-        sal tissue. Am J Surg Pathol 1986;1:34-47.
thelioma. We can find only one other report in which similar 3 Kutty K, Varkey B. Incidence and distribution of intrathoracic
                                                                  metastases from renal cell carcinoma. Arch Intern Med
observations have been made.' In that case, however, paren-       1984;144:273-6.
chymal lung disease was also a feature. In our patient exten- 4 Riches EW. Tumours of the kidney and ureter. In: DW Smithers,
sive pleural tumour was the sole intrathoracic abnormality.       ed. Neoplastic disease at various sites. Vol 5. Edinburgh: ES
   Although confirmed histologically to be a renal cell car-      Livingstone, 1964:72-85.
cinoma metastasis, the tumour in the present case had 5 Latour A, Shulman HS. Thoracic manifestations of renal cell car-
spread throughout the left hemithorax in a contiguous man-        cinoma. Radiology 1976;121:43-8.
ner, a pattern typical of mesothelioma. Because of the his- 6 Shearin GC, Jackson D. Malignant pleural mesothelioma-
                                                                  report of 19 cases. J
tory of asbestos exposure and the initial radiological 7 Bush WH, Burnett LL,Thoracic Cardiovasc Surg 1976;71:621-6.
                                                                                         Gibbons RP. Needle track seeding of
appearances, mesothelioma had been the clinical diagnosis;        renal cell carcinoma. Am J Roentgenol 1977;129:725-7.
the abdominal mass was thought to be a benign renal cyst. It 8 Selikoff IJ, Hammond EC, Seidman H. Mortality experience of
is interesting to speculate that the pleural thickening and       insulation workers in the United States and Canada,
subpleural asbestos fibres with fibrous reaction, presumed to     1943-1976. Ann NY Acad Sci 1979;330:91-116.

				
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